At the beginning of the fourth stage of labor the nurse assess what four things? (Select four correct answers).
Fundal tone
Lochia
Transcutaneous bilirubin
Engorgement
Vital Signs
Bladder distension
Correct Answer : A,B,E,F
A. Fundal tone assessment helps detect uterine atony.
B. Lochia assessment monitors postpartum bleeding.
C. Transcutaneous bilirubin is not assessed in the immediate postpartum period.
D. Engorgement relates to breastfeeding and is not a priority in the fourth stage.
E. Vital signs are crucial to monitor for hemorrhage or shock.
F. Bladder distension can affect uterine contraction and bleeding.
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Related Questions
Correct Answer is A
Explanation
A. Trichomonas is a sexually transmitted infection that typically causes a frothy, malodorous vaginal discharge, so this response shows an understanding of the condition.
B. Painful urination is more characteristic of a urinary tract infection or gonorrhea, not syphilis.
C. Condoms greatly reduce the risk of STDs but do not provide 100% protection, so this statement is incorrect.
D. A cesarean section is not always necessary for women with herpes; it is only recommended if there are active lesions at the time of delivery to prevent transmission.
Correct Answer is B, D, A, C
Explanation
Urine hCG is used to confirm pregnancy and is the first test performed. The maternal serum alpha-fetoprotein test is typically done around 15-20 weeks to screen for fetal abnormalities. The Glucose Tolerance Test (GTT) is typically performed between 24-28 weeks to screen for gestational diabetes. Group B beta strep testing is usually done between 35-37 weeks to screen for bacterial infection.
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